Benjamin Fox

Relative and absolute reliability of functional performance measures for adults with dementia living in residential aged care

BACKGROUND This pilot investigation aimed to assess the relative and absolute test-retest reliability of commonly used functional performance measures in older adults with dementia residing in residential aged care facilities. METHODS A total of 12 participants were tested on the Short Physical Performance Battery (SPPB), the Balance Outcome Measure for Elder Rehab (BOOMER), hand grip strength, anthropometric measures and Bio-electric Impedance Analysis (BIA). This study utilized a seven-day test-retest evaluation. Intra-class Correlation Coefficients (ICC) were used to assess relative reliability, Typical Error of Measurement (TEM) was used to assess the absolute reliability, and Bland-Altman plots were used to assess group and individual levels of agreement. RESULTS With the exception of Standing Balance (ICC = 0.49), 2.4-m walk (ICC = 0.68), functional reach (ICC = 0.38), and static timed standing (ICC = 0.47), all measures demonstrated acceptable (>0.71) ICCs. However, only the anthropometric measures demonstrated acceptable levels of absolute reliability (>10% TEM). Bland-Altman analysis showed non-significant (p > 0.05) mean differences, and eight out of the 17 measures showing wide Limits of Agreement (LoA). CONCLUSIONS Current measures of functional performance are demonstrably inappropriate for use with a population of older adults with dementia. Authors suggest aligning current measurement strategies with Item Response Theory as a way forward.

Reliability of functional performance in older people with dementia

Research into the benefits of exercise for cognitively compromised adults is promising and the interest in this area is growing [1]. While data are mixed, a number of studies show important benefits through exercise and physical activity for cognitively compromised older adults, including reduced agitation, behavioural symptoms and depression, and improved coordination, memory and capacity in activities of daily living [2–4]. Importantly, exercise has the potential to reduce care-related expenses and dependence issues, and improve quality of life, self-worth and patient dignity.

Adherence to a standardized protocol for measuring grip strength and appropriate cut-off values in adults over 65 years with sarcopenia: a systematic review protocol

Review question/objective The objective of this review is to examine the use of grip strength analysis in well and unwell populations in adults 65 years and over as a tool to establish muscle strength in sarcopenia. More specifically, the main review question is: 1. What protocol, if any, is most commonly used among older adults with sarcopenia and does this match the standardized protocol suggested in 2011 by Roberts et al.1? Secondary review questions are: 2. What are the reported cut‐off values being used to determine sarcopenia in older adults, with consideration for ethnic and gender variability? 3. Is grip strength, as a tool to measure muscle strength, suitable for people with common comorbidities and geriatric syndromes, such as osteoarthritis, often associated with sarcopenia? Background Sarcopenia, a commonly used concept in geriatrics and gerontology, is characterized by a loss of muscle mass, muscle strength and/or physical functioning.1 Prevalence rates vary between 1‐39% in community dwelling older populations and 14‐33% in long‐term care populations.2 Several epidemiological studies have shown the association of sarcopenia with adverse health outcomes such as falls, disability, hospitalization and mortality.3‐4 Originally, sarcopenia refers to the loss of muscle mass with aging5, which was later complemented with loss of muscle strength and physical functioning. In 2010, the European Working Group on Sarcopenia in Older People (EWGSOP) reported a consensus definition of sarcopenia, which included measurement of low muscle mass and low muscle function (strength or physical performance).1 This consensus definition can be used to identify sarcopenia patients in clinical practice and to select individuals for clinical trials. Well‐designed clinical trials could ultimately lead to effective treatment and prevention strategies for sarcopenia. Since the publication of the consensus report, many studies have adopted this definition, which could potentially lead to better comparison of results between studies. On the other hand, within this definition there still is wide variability in measurement tools and use of cut‐off values, which could actually hamper comparability between studies. To assess muscle strength, the EWGSOP has recommended grip strength measurement which is easy and inexpensive. A recent systematic review on the measurement properties of tools to assess sarcopenia concluded that grip strength measurement is a valid and reliable method.6 In a comprehensive review of the measurement of grip strength in clinical and epidemiological studies by Roberts et al.,7 it was shown that there is wide variability in the choice of equipment and protocols for measuring grip strength. To enable comparison between studies, a standardized approach, incorporating more consistent measurement of grip strength is warranted. Based on the results of the review, a standardized approach was described7 including the utilization of the widely used Jamar hydraulic hand dynamometer, as was a clear assessment protocol. So far, it is unknown whether this approach has been adopted in studies investigating grip strength for sarcopenia. The primary aim of this current review is to identify whether studies are adhering to the suggested protocol, or whether a more common method is prevalent. The EWGSOP has suggested multiple cut‐off values to define sarcopenia regarding muscle strength: an absolute cut‐off score of 20 kilograms (kg) for women and 30 kg for men,8 and Body Mass Index (BMI) specific cut‐off values for men and women.9 Alternatively, the Foundation for the National Institutes of Health (FNIH) Sarcopenia Study suggested cut‐off points of 26kg for males and 16kg for females, based on the likelihood of mobility impairment.10 Similar values have also been suggested by Dodds et al.,11 who generated grip strength reference values and calculated cut‐off points 2.5 standard deviations below the mean from 12 United Kingdom (U.K)based epidemiology studies. Recently, Beaudart et al.12 showed that large differences in sarcopenia prevalence occur when both cut‐off values are compared, especially in women.12 Additionally, prevalence has also shown to be dependent upon the tool used to assess muscle strength.13 Evidently, cut‐off values are highly varied and may be selected for statistical, theoretical or practical reasons, and/or are based on the type and magnitude of association with clinical endpoints such as hospitalization, falls or mobility. Difficulties arise in promoting a clear‐cut definition of sarcopenia with no consistent recommendation for cut‐off values of grip strength available. It is therefore important to identify which grip strength cut‐off values should be used for the identification of sarcopenia patients and how comorbidities such as osteoarthritis may affect such values. This review will aim to report on the cut‐off values used, the justification for and the considerations of comorbidities within the identified articles. Furthermore, a study has suggested that cut‐off values may be different within Asian populations. Therefore, ethnicity will also be taken into account for variations in appropriate cut‐off values.14 The overarching objective of this review is to provide insight into the current use of grip strength within the literature among older adults aged 65 and over and, subsequently, to provide commentary on the consistency of protocol and cut‐off values reported for grip strength measures. This insight into current research practice will lead to well‐considered recommendations concerning the measurement of grip strength in research and clinical practice. A preliminary search for sarcopenia revealed five systematic reviews in the Cochrane Library and two within the JBI Database of Systematic Reviews and Implementation Reports, but none that examine the protocol of grip strength measures. A single study was identified through a search of Medline [Via EBSCOhost] which examines the psychometric properties of common measures of muscle mass, strength and physical performance in sarcopenia6, but it was not specific to grip strength measures, nor did it examine the used protocol within studies. A lack of research into this area warrants further research and the need for the conduct of this proposed review.

Psychometric viability of measures of functional performance commonly used for people with dementia: A systematic review of measurement properties.

BackgroundConfidence in findings can only be drawn from measurement tools that have sound psychometric properties for the population with which they are used. Within a dementia specific population, measures of physical function have been poorly justified in exercise intervention studies, with justification of measures based on validity or reliability studies from dissimilar clinical populations, such as people with bronchitis or healthy older adults without dementia. ObjectivesTo review the reliability and validity of quantitative measures of pre-identified physical function, as commonly used within exercise intervention literature for adults with dementia. Inclusion criteria Types of participantsParticipants were adults, aged 65 years and older, with a confirmed medical diagnosis of dementia. Types of intervention(s)/phenomena of interestn/a Types of studiesDesired studies were observational and cross-sectional and that assessed measures from a pre-identified list of measures of physical function. OutcomesStudies that assessed the psychometric constructs of reliability and validity were targeted. COSMIN taxology was used to define reliability and validity. This included, but were not limited to, Intra-Class Correlations, Kappa, Cronbachs Alpha, Chi Squared, Standard Error of Measurement, Minimal Detectable Change and Limits of Agreement. Search strategyPublished material was sourced from the following four databases: MEDLINE, EMBASE, CINAHL and ISI Web of Science. Grey literature was searched for using ALOIS, Google Scholar and ProQuest. Methodological qualityThe COSMIN checklist was used to assess methodological quality of included studies. Assessment was completed by two reviewers independently. Data extractionReliability and validity data was extracted from included studies using standardized Joanna Briggs Institute data collection forms. Extraction was completed by two reviewers. Data synthesisA narrative synthesis of measurement properties of the tools used to measure physical function was performed. Quantitative meta-analysis was conducted for Intra-Class Correlation Coefficients only. ResultsWith respect to relative reliability, studies reporting assessed measures had intraclass correlation coefficients greater than 0.71, indicating their suitability for use at a group level. However, a consistent finding among studies that included assessment of absolute reliability was that intra individual variation was too large for meaningful measurement of individuals. This was indicated by large Minimal Detectable Change (MDC) scores. Walk Speed has the smallest reported Mimimal Detectable Change score at 0.11m/s. This represented a change of 35% before statistical variation could be eliminated as the cause for this change. All measures had large MDC values. Walk Speed had the smallest MDC values at 0.11m/s, which represented a necessary change of 35%. Only a limited number of studies assessed the validity of measures. This supports the use of these measures in a very narrow selection of circumstances (see Summary of Findings). ConclusionsIn summary, measures have shown appropriate levels of relative reliability. This supports their use at the group level. However, large levels of intra-individual variation undermine their applicability at the individual level. Limited studies of validity were available to this review, which limits a conclusion on whether measures are valid for people with dementia.